Cutaneous Malignancies: Presentation and Outcome in a Plastic Surgical Unit Hameed-Ud-Din et al

Original Article

Hameed-Ud-Din*
C utaneous M alignancies: Presentation Muhammad Saaiq**
Muhammad Ibrahim Khan***
and O utcom e in a Plastic Surgical U nit
*Assistant Professor and Head
Objective: The study was undertaken to document the presentation and outcome of **Trainee Registrar
cutaneous malignancies in our set up. ***Senior Registrar
Study Design: Descriptive study. Department of Plastic Surgery,
Place and Duration: This study was carried out in the Department of Plastic and PIMS, Islamabad.
Reconstructive Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad during
the period from July 01, 2006 to June 30, 2008.
Materials and Methods: All patients who presented with various cutaneous
malignancies at our department were included in the study by convenience sampling
technique. Those patients who did not consent to participate in the study were
excluded. Initial assessment and diagnosis was made by history, physical examination
and fine needle aspiration cytology (FNAC). Wedge / excision biopsies were performed in all
patients. Local extent of tumour was assessed with CT scan in selected patients. The
sociodemographic profile of the patients, type of malignancy, type of surgical procedure
undertaken, complications encountered, morbidity and mortality were all recorded on a
proforma. The data were subjected to statistical analysis.
Results: Out of a total of 103 patients, 56.31% (n=58) were males while 43.68 % (n=45)
were females. The mean age was 53 ± 17 years. There were 55 cases of BCC, 40 cases of
SCC, 6 cases of malignant melanoma, and one case each of trichilemmal carcinoma and
dermatofibro-sarcoma protuberance (DFSP). Face was the most frequent site of
involvement ( n=72 ), followed by leg ( n=9 ), neck ( n=6 ), arm ( n=5 ), scalp ( n=4 ), hand
( n=3 ), chest ( n=2 ), and back ( n=2).
The rate of hospitalisation was 12.62%(n=13). The average hospital stay was 5 days (range
3-9days). There was no in-hospital mortality.
Conclusion: Cutaneous malignancies constitute a significant source of morbidity and
hospitalization especially in the elderly population. In our set up, BCC constitutes the
leading type followed by SCC. Painless skin lesion of a relatively longer duration is the
usual presenting feature. Surgical excision and reconstruction of the defect with skin
graft or flap is the most frequently instituted definitive treatment. A good percentage of our Address for Correspondence:
patients present late with locally advanced cancer and are not amenable to surgical Dr. Muhammad Saaiq,
excision, necessitating radiotherapy or chemotherapy. Trainee Registrar Department of Plastic
Key words: Cutaneous malignancies. Non-melanoma skin cancers. Basal cell carcinoma. Surgery, PIMS, Islamabad.
Squamous cell carcinoma. Malignant melanoma. msaaiq@yahoo.uk.com

of skin cancer and the amount of ultraviolet (UV) light

Introduction
Cutaneous malignancies constitute one of the
most common human malignancies. Annually, more
than 400,000 people find out they have skin cancer.
Etiology is related to various factors such as skin type,
age, sun exposure and many other factors.
Predisposing factors include individuals with a fair or
light complexion, a history of severe sunburns, poor
tanning capability, inherited disorders (e.g. xeroderma
pigmentosa, albinism etc.), and immunocompromise
1-3
etc. A linear correlation exists between the frequency
exposure. The exaggerated and repeated exposure to
UV light emanating from the sun is regarded as the most
important risk factor for skin cancer. This exposure is
increased owing to depletion of ozone layer which
normally restricts the transmission of type B and C UV
light. Early recognition and biopsy of suspected lesions
greatly improves outcomes.
4, 5
The skin cancers are classified into melanomas
and non-melanoma skin cancers (NMSC). Basal cell
carcinoma (BCC) and Squamous cell carcinoma (SCC)
are the commonest types of non melanoma skin

Ann. Pak. Inst. Med. Sci. 2009; 5(2): 1

Cutaneous Malignancies: Presentation and Outcome in a Plastic Surgical Unit
2
cancers . Although having greater incidence, the
mortality of BCC and SCC is still low as compared to the
6
alarmingly high mortality of malignant melanoma.
Malignant melanoma poses an emerging challenge as
increasingly number of individuals are affected by it. Its
incidence is estimated to be rising by almost 6% per
7, 8
year.
Cutaneous malignancies are not uncommon in
our population. Most of our patients present with fairly
advanced stage. The present study was undertaken to
measure the frequency of cutaneous malignancies in
our set up, analyse the sociodemographic profile of the
patients, assess the associated morbidity and mortality
and collect actionable evidence base for evolving
meaningful strategies to address this emerging public
health issue.
Hameed-Ud-Din et al
the types of malignancies, body area distribution of the
tumours, interventional procedures employed and
complications observed were expressed as frequency
and percentages.
Results
Out of a total of 103 patients with various
cutaneous malignancies, 56.31% (n=58) were males
while 43.68 % (n=45) were females. The mean age was
53 ± 17 years. There were 55 cases of BCC, 40 cases
of SCC, 6 cases of malignant melanoma, and one case
each of trichilemmal carcinoma and dermatofibro-
sarcoma protuberance (DFSP). Face was the most
frequent site of involvement ( n=72 ), followed by leg (
n=9 ), neck ( n=6 ), arm ( n=5 ), scalp ( n=4 ), hand
( n=3 ), chest ( n=2 ), and back ( n=2).

Materials and Methods

Table I: Gender-Wise distribution of the
This study was carried out in the Department of
Plastic and Reconstructive Surgery, Pakistan Institute of
patients (n=103)
Medical Sciences (PIMS), Islamabad during the period No. OF No. OF
MALIGNANCY MALE FEMALE p- Value
from July 01, 2006 to June 30, 2008.
PATIENTS PATIENTS
All patients who presented with various (%) (%)
cutaneous malignancies at our department were BCC 29(52.72%) 26 (47.27 %) >0.005
prospectively included in the study. Convenience SCC 21 (52.50%) 19 ( 47.50% ) >0.005
sampling technique was employed. Those patients who MELANOMA 6 (100%) - <0.005
did not consent to participate in the study were DFSP 1 (100%) - <0.005
excluded. Initial assessment and diagnosis was made TRICHILEMM 1 (100%) - <0.005
by history, physical examination and fine needle AL CA
aspiration cytology (FNAC). Wedge / excision biopsies
were performed in all patients. Local extent of tumour Table II: Various interventional
was assessed with CT scan in selected patients. procedures undertaken in the patients
Additionally the basic essential work up was done in
patients undergoing surgical excision of the tumour and
(n=103).
reconstruction of the defects. All the patients were INTERVENTIONAL No. OF PATIENTS (%)
managed according to the standard oncologic principles PROCEDURES
1,3,7
of cutaneous malignancies . Any reconstructive Wedge biopsy / 103(100%)
surgical procedure required was instituted according to Excision biopsy
the condition of the individual patients and their defects. Wide local Excision of 92(89.32%)
The sociodemographic profile of the patients, the tumour
type of malignancy, type of surgical procedure Re-resection of 14(15.21%)
undertaken, complications encountered, morbidity and positive Margins
mortality were all recorded on a proforma. Figures I Skin grafts 77 (83.69%)
through VI show some representative pictures of the Flap Coverage 15(16.30)
included patients. Groin Lymph Node 3(3.2%)
clearance
Statistical Analysis Table III: Various complications
The data were analysed through SPSS encountered among the patients (n=103)
version 10 and various descriptive statistics were used COMPLICATONS No. OF PATIENTS (%)
to calculate frequencies, percentages, means and Wound infection 2 (2.17%)
standard deviation. The numerical data such as age Partial graft rejection 3(3.26%)
and duration of hospitalization was expressed as Mean Full graft rejection 1 (1.08%)
± Standard deviation while the categorical data such as Flap tip necrosis 1 (1.08%)

Ann. Pak. Inst. Med. Sci. 2009; 5(1): 2

Cutaneous Malignancies: Presentation and Outcome in a Plastic Surgical Unit Hameed-Ud-Din et al

Figure I: Recurrent BCC of 13 Years Figure IV: SCC of Hand

Duration.

Figure V: Marjolin Ulcer (SCC) developing

in a 17 Years old Postburn Scar.
Figure II: Multiple SCCs in a patient with
Albinism.

Figure VI: Malignant melanoma developing

on Heel.
Figure III: Multiple SCCs in a patient with
Xeroderma Pigmentosa.

Ann. Pak. Inst. Med. Sci. 2009; 5(1): 3

Cutaneous Malignancies: Presentation and Outcome in a Plastic Surgical Unit
Residence-wise, 45.63% ( n=47 ) patients were
from the twin cities of Islamabad and Rawalpindi,
32.03% ( n=33 ) from Azad Jammu Kashmir, 18.44% (
n=19 ) from Upper Punjab, 2.91% ( n=3 ) from NWFP,
and one patient ( 0.97% ) was Afghan refugee.
Painless skin lesion was the most common
presenting feature (n=103), followed by non-healing
ulcer in a previous scar (n=13) and changes in a pre-
existing mole (n=6).
Gender-wise distribution of the various
malignancies is shown in Table I. The various surgical
procedures undertaken are depicted in Table II. Table
III shows our share of complications. The rate of
hospitalisation was 12.62 %( n=13). The average
hospital stay was 5 days (range 3-9days). There was
no in-hospital mortality.
Discussion
103 patients of skin malignancies over two
years period indicates a high frequency of cases in our
set up. Skin cancer is found to be more common among
Caucasians as compared to Africans, Asians, Latin-
Americans, and American-Indians. However in these
later groups greater morbidity and mortality has been
observed owing to atypical presentations in these
9
groups. Internationally a rising trend has been
shown in the incidence of cutaneous malignancies. For
instance non-melanoma skin cancers, which constitute
the most common cancer in Australia have shown an
alarmingly rise in its incidence over the last two
decades. BCC’s incidence has increased by 19 %
between 1985 and 1995 while the incidence of SCC has
10
increased by 93 % over the same period . The
incidence of malignant melanoma has risen by an
11, 12
average 3%–7% over the last several decades
Increased exposure to UV light emanating from the sun
secondary to depletion of the ozone layer is considered
to be the most important aetiologic factor responsible for
5
the increased incidence of cutaneous malignancies.
This has been compounded by changes in clothing
13
habits and life styles over the past half century.
In our study an overall slight male
preponderance was seen among the patients. i.e.
males were 58 while females were 45. In patients with
BCC and SCC the incidence was slightly higher among
males than females but the difference was statistically
insignificant, however all six cases of malignant
melanoma and each of the trichilemmal carcinoma and
DFSP were found exclusively in males. Higher incidence
of these malignancies has also been reported by other
14,15
local studies . In the US, the rate of NMSC among
men has been reported to be twice that among women.
6
The higher incidence of malignant melanoma among
11
men is reported by other published studies as well .
In our study the patients’ mean age was 53
Ann. Pak. Inst. Med. Sci. 2009; 5(1):
Hameed-Ud-Din et al
years. Our youngest patient was of 9 years. He had
SCC and was a case of xeroderma pigmentosa. Our
eldest patient was 82 and had BCC. A Karachi base
study reported patients with age ranging from 8 - 92
years in a study of 75 cutaneous cancers patients. 16
Another local study reported patients ranging in age
15
from 15 to 103 years .
In our study 93.20 % of the cutaneous
malignancies were NMSC. Out of these BCC and SCC
did not differ widely with respect to their frequency.
These findings are in conformity with those of another
16
local study , but in sharp contrast to the Western data
that show the incidence of BCC to be 3-4 times greater
1-3
than that of SCC . A local study has reported SCC as
15
the most frequent skin cancer . In dark skinned ethnic
groups, SCC has been shown to be the most commonly
encountered cutaneous malignancy and exposure to
ultraviolet light has been found to be un-important
17
etiologic factor in this regard .
In the majority of our patients with BCC and
SCC, we employed surgical excision as the mainstay of
management. Subsequent reconstructions of the
defects were done with skin grafts and different flaps.
Cure rates depend on the size, histotype, and anatomic
location of the lesion. In BCC, margins of 5 mm are
recommended to achieve cure. In SCC, 4 mm margins
for lesions less than 2 cm and 1cm for larger lesions are
recommended. "The larger the lesion, the wider the
margin" is a good general rule. Recurrence rates are
higher in tumors wider than 3 cm or in areas where
maximum tissue preservation is required. Positive
margins after primary resection must be re-excised for
cure. Recurrent tumors require larger surgical margins
than those used in primary resections .
1-3
For primary lesions (of BCC and SCC) of non-
critical areas, smaller than 2 cm, certain alternative
. management modalities exist and are often used by
dermatologists. e.g. electrodesiccation and curettage,
cryotherapy etc. The cure rates for these treatment
modalities reportedly are 90%-98%. There are certain
disadvantages associated with these techniques. For
instance, these do not provide any resection specimen
for histological confirmation of oncologic clearance. The
recurrence rates are around 50% for tumors wider than
1-3
3 cm . Cryosurgery also causes significant scarring,
hypopigmentation, and potential injury to adjacent
nerves. Scar contracture may cause problems
2, 18
especially in the periorbital or perioral lesions .
Though not yet available in Pakistan, Mohs
micrographic surgery (MMS) is in vogue in the
developed countries. It is a tissue sparing technique
employed for managing primary and recurrent BCC and
SCC of critical areas. It entails horizontal frozen sections
of the entire undersurface of the excised tissue,
microscopic examinations of the sections and then plan
the extent of the resection accordingly. It has
4
Cutaneous Malignancies: Presentation and Outcome in a Plastic Surgical Unit
advantageous in critical areas, such as the medial and 3.
lateral canthi, perioral area, and nasal ala etc. Cure
rates for this technique are higher than surgical excision,
for instance for BCC the cure rate is 99% for primary 4.
2, 3, 19, 20
lesions and 96% for recurrent lesions . Most of
the authorities do not consider MMS a prudent
7, 19, 21
management option for malignant melanoma . 5.
Eleven of our patients had locally advanced
irresectable malignancies. Lack of awareness, public 6.
apathy regarding health issues. poverty etc are few of
the reasons for delayed presentation. Such patients
with late presentation often have locally advanced 7.
cancer, not amenable to surgical excision, necessitating
radiotherapy or chemotherapy. There is need of mass 8.
awareness to prompt early medical consultation in such
neglected cases. The patients with locally advanced
cancers were referred to NORI for radio-chemotherapy.
Radiotherapy has been sown to be effective in old 9.
patients who are poor surgical candidates
3.
There was no in-hospital mortality; however the
patients with malignant melanoma were potential non-
10.
survivors.
Conclusion
11.
Cutaneous malignancies are not uncommon in
our set up. These constitute a significant source of 12.
morbidity and hospitalization especially in elderly
population. In our set up, BCC constitutes the leading
type followed by SCC. Painless skin lesion of a 13.
relatively long duration is the usual presenting feature.
Surgical excision and reconstruction of the defect with 14.
skin graft or flap is the most frequently instituted
definitive treatment. A good percentage of our patients
15.
present late with locally advanced cancer and are not
amenable to surgical excision, necessitating
radiotherapy or chemotherapy. There is intense need of
mass awareness and to foster knowledge about the 16.
medical and socioeconomic implications of this
emerging health issue. This will help not only help to 17.
prevent the avoidable causes but also prompt early
medical consult in case an individual develops such skin 18.
lesions.
19.
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